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Revista Mexicana de Ortodoncia

Vol. 3, No. 2 April-June 2015 Case report pp 105-111

O rthodontic treatment for a craniomandibular disorder. Case report Tratamiento ortodóntico de la disfunción craneomandibular. Reporte de caso clínico

Hadyt Pazarón Salgado*, Isaac Guzmán Valdivia§

Abstract Resumen

Female patient 13 years of age with severe TMJ dysfunction Paciente femenino de 13 años de edad, con severa disfunción cra- who presented symptoms of pain and generalized muscular neomandibular. Presenta sintomatología dolorosa e hipertonicidad hypertonicity, vertigo, difficulty for walking, limitation of mandibular muscular generalizada, vértigo, dificultad para caminar, limitación movements, weak chewing and maximum oral opening of 17 mm. de movimientos mandibulares, masticación débil y apertura bucal She was diagnosed as a skeletal Class II due toretrognathia and máxima de 17 mm clase II esqueletal por retrognatismo mandibular, micrognathia. She had a convex profile, severe upper and lower micrognatismo, perfil convexo, severo apiñamiento dental anterior anterior dental crowding. Treatment began with neuromuscular superior e inferior. Los objetivos del tratamiento fueron lograr una reprogramming with a splint for muscular relaxation, thermotherapy oclusión estable, mejorar el tono muscular y la función craneoman- with moist heat, muscle relaxants and afterwards, orthodontic dibular. Disminuir en lo posible el dolor, obtener una apertura bucal treatment. The results of the treatment were satisfactory since the adecuada. El tratamiento inició con reprogramación neuromuscular patient experienced improvement in her physical and emotional con férula de miorrelajación, termoterapia con calor húmedo, rela- health. Correct masticatory function was restored giving the patient jantes musculares y posteriormente tratamiento ortodóntico. Los a better quality of life and allowing her to resume her normal daily resultados del tratamiento fueron satisfactorios, ya que la paciente activities. experimentó mejoría en su salud, física y emocional. Se recuperó la correcta función masticatoria, brindándole a la paciente una mejor calidad de vida, reintegrándose a sus actividades cotidianas.

Key words: TMJ dysfunction, mandibular retrognathism, muscular hypertonicity. Palabras clave: Disfunción craneomandibular, retrognatismo mandibular, hipertonicidad muscular.

Introduction A correct diagnosis will lead to a successful treatment. There are different ways of treating CMD. Craniomandibular dysfunction (CMD) is a complex Diagnosis of the craniomandibular dysfunction and multifactorial disorder that may cause 2 types of should be carried out by means of a thorough alterations: local and systemic. evaluation of the stomatognathic system, which One of the most frequent etiologies is stress. includes basically a complete medical history and The more susceptible structures are: muscles, the a thorough physical examination which may be temporomandibular joint (TMJ), teeth and their supplemented with imaging tests. supporting structures. The body reacts to the stressingwww.medigraphic.org.mx factor making demands for readjustment or adaptation. The magnitude of such adaptation will depend on the amount of stress. Muscles experience pain upon palpation and during mandibular movements. The * Graduate. § Professor. patient describes it as a limitation of movement with associated pain, tenderness, joint pain, clicking and Department of at the University of Latin America, Campus wear on the teeth. Valle, México, D.F. CMD is a multifactorial disease that must be treated This article can be read in its full version in the following page: multi-disciplinarily. http://www.medigraphic.com/ortodoncia Pazarón SH et al. Orthodontic treatment for a craniomandibular disorder 106

The main signs and symptoms of TMJ disorders Craniomandibular are associated with a disruption of the disc-condyle dysfunction diagnosis complex. Epidemiological studies suggest that approximately Clinical chart, physical exam, functional analysis, 30% of the general population shows some sign of radiographic diagnosis and diagnostic aids (videos, functional alteration of the masticatory system. photographs, study models).

Craniomandibular Craniomandibular dysfunction dysfunction etiology treatment

Stress, muscle hyperactivity, premature contact Treatment of the CDM is classified into 2 types: points, bruxism and trauma. 1. Final: It is aimed to control or eliminate etiologic Craniomandibular dysfunction factors. signs and symptoms 2. Supportive: They are therapeutic to modify symptoms. Pain, myofacial pain syndrome, trigger points, articular sounds(clicking and crackling), periauricular Another way for classifying CDM treatment is the pain, dizziness and vertigo, limitation of mandibular following: palliative therapy, natural resolution, therapy movements, , alterations at joint level related to the cause, specific therapy and rehabilitation. (morphologic alterations, adhesions, dislocation, Treatment is performed by means of a myo- inflammatory disorders of the TMJ, inflammatory relaxation splint, medications, physical therapy, disorders of associated structures) and decreased thermotherapy, transcutaneous electrical nerve visual acuity. stimulation (TENS), type ABotox, ultrasound, laser,

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Figure 1.

Facial photographs and maximum opening of the patient. Revista Mexicana de Ortodoncia 2015;3 (2): 105-111 107

psychotherapy, orthodontic appliances and surgical treatment.

Case report

Female patient of 13 years of age with very strong painful symptoms and generalized muscular hypertonicity, vertigo, inability to walk, limitation of mandibular movements, weak chewing and maximum oral opening of 17 mm (Figures 1 and 2). She was referred from Neurology, and her reason for consultation was to eliminate the pain. Cefalometrically, she presented a skeletal class II due to retrognathism, micrognathia, a tendency to Figure 2. horizontal growth, bi-proclinationand dentoalveolar Photographs of the bi-protrusion. Facial analysis showed a convex patient’s posture.

Figure 3.

Initial intraoral photographs.

Increased Decreased

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Figure 4.

Panoramic radiograph, lateral headfilm and cephalometric tracing. Pazarón SH et al. Orthodontic treatment for a craniomandibular disorder 108

profile and bi-prochelia. She suffered from bilateral 9. Phase III: consolidation and stabilization 0.019” x TMJ pain as well as widespread muscle pain. 0.025”-0,021” x 0.025” SS archwires. Functionally, the patient performed abnormal 10. Phase IV: occlusal settling. and limited opening and closing movements and 11. Retention. there was a generalized muscle contracture, tongue thrusting, lip suction and weak chewing. In relation Treatment progress to her dental features, she had a left and right non- assessable canine class, severe upper and lower First Robaxisal, a muscle relaxant, was prescribed: anterior crowding, increased and , 1every 8 hours for 15 days, coupled with hot -water deviated dental midlines and upper and lower non- bags and massage of the face and neck muscles 3 ideal archform (Figures 3 and 4). times a day as palliative therapy. An upper myo- relaxation splint was placed (Figure 5) and the Treatment plan patient´s appointments were scheduled every 15 days for review of the contact points and wear on the splint, Therapy with muscle relaxants and thermotherapy which were smoothed. The appliance was worn for 3 with moist heat. months, time required to determine if the problem was caused by the malocclusion. When the mouth opening, 1. Neuromuscular reprogramming with myo-relaxation the chewing and the pain improved it was confirmed splint. that the treatment would be orthodontic and that the 2. Upper and lower first premolar extractions. problem was not caused by a systemic problem such 3. 0.022” Roth system. as juvenile rheumatism thus treatment was begun. 4. Phase I. Initial aligning and leveling 0.014”-0.016” Upper and lower first premolar extractions were NiTi archwires. performed. Molar bands and 0.022 slot Roth brackets 5. Phase II-1. Second and third order movements were placed on the upper and lower arch. Phase 0.016” x 0.016” NiTi to 0.019” x 0.025” SS 1consisted in initial aligning and leveling with 0.014 archwires. NiTi archwires. Phase II, the arches were coordinated 6. Phase II-2: retraction of the anterior segment with through light second and third order movements. 0.019” x 0.025” SS DKL archwires. was obtained through mini-implants. 7. At this stage, the possibility of using mini-implants Retraction of the anterior segment was done with a DKL for upper anchorage would be re-assessed. archwire and all spaces were closed. Consolidation, 8. Posterior space closure. stabilization and retention (Figures 6 to 9).

Figure 5.

Myo-relaxation splint.

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Figure 6.

Beginning of treatment, 0.014 NiTi archwires. Revista Mexicana de Ortodoncia 2015;3 (2): 105-111 109

Results Craniomandibular function was improved by eliminating the widespread muscle pain. An opening The facial and intraoral photographs, the X-rays and and closing pattern without deviation was attained, the functional analysis show completely satisfactory obtaining a maximum opening of 38 mm. Oral habits results since the axial axis of the teeth was corrected were corrected and adequate masticatory function and dentoalveolar biprotrusion decreased. The was recovered. Bilateral molar and canine class I was profile improved by decreasing the biprocheilia. obtained. Dental crowding was eliminated and the

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Figure 7.

Mini-implant placement to achie- ve skeletal anchorage and retract adequately the upper right ante- rior segment.

Figure 8.

DKL archwire activation on the right side. Reverse curve 0.017” x 0.025” NiTi.

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Figure 9.

0.019” x 0.025” continuous stain- less steel archwires. Pazarón SH et al. Orthodontic treatment for a craniomandibular disorder 110

overbite, overjet and dental midlines were corrected. Conclusions Arch shape was improved (Figures 10 to 12). All treatment objectives were achieved Craniomandibular dysfunctions are each day more demonstrating that in cases such these, if they are frequent in our population, affecting more women than properly diagnosed and treated, patient’s health may men and with an increasing incidence in children and be restored. teenagers.

Figure 10.

End of treatment, impressions were taken to fabricate the retainers. A circumferential was placed on the upper arch and a 0.0175 archwire fixed retainer on the lower.

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Figure 11.

Final facial photographs and maximum opening. Revista Mexicana de Ortodoncia 2015;3 (2): 105-111 111

Increased Increased Decreased Decreased

Figure 12.

Comparative cephalometric tra- cings at the beginning and end of treatment where significant chan- ges may be observed.

This disease is multifactorial therefore it should be — Farrar WB, Mc Cart WL. The TMJ dilemma. J Am Dent Assoc. treated multi-disciplinarily in order to obtain an integral 1979; 63: 8-11. — Carlsson G. Epidemiology and treatment need for temporomandibular result that involves facial, articular, functional, dental, disorders. J Orofac Pain. 1999; 13: 232: 15-19. aesthetic, psychological, social, and emotional changes. — Castaneda R. Occlusion and temporomandibular disorders. There are currently different alternatives to deal with Philadelphia: Saunders. 1992, pp. 40-49. the CMD so it is important to be trained to implement — Bell W. Temporomandibular disorders: Classification, Diagnosis and Management, 2ª ed. Mosby, EUA. 1986. the most appropriate for each patient and in this way — Smith SR, Phillips C, Tyndall DA. Quantitative and Subjective manage pain and relieve the patient’s suffering. analysis of temporomandibular joint radiographics. J Prosthet The main challenge for the orthodontist in CMD Dent. 1989; 62: 456-463.1989; 62 (4): 456-63. cases is the diagnosis in order to determine the — Seyle H. Confusion and controversy in the stress field. J Human Stress. 1975; 1 (2): 37-44. extent to which the malocclusion is affecting the — de Kloet ER, Joëls M, Holsboer F. Stress and the brain: from craniomandibular problem. adaptation to disease. Nat Rev Neurosci. 2005; 6 (6): 463-475. — Miller A, Vargervik K. Neuromuscular changes during long-term Recommended readings adaptation of rhesus monkey to oral respiration. In: Mc Namara JA Jr, ed. Naso-respiratory Function and Craniofacial Growth. Craniofacial Growth Series, Monograph 9. Ann Arbor, Michigan: — Okesson JP. Bell’s orofacial pains. 5ª ed. Chicago: Quintessence, Center for Human Growth and Development, Universtity of Publishing Co, Inc; 1995, pp. 295-343. Michigan; 1979, pp. 1-26. — Fernando AM, Marcela RR. Dolor orofacial y desórdenes de la — Travell J, Simons D. Myofascial pain and dysfunction: the trigger articulación temporomandibular. Ed. Trillas; 2006, pp. 105-135. point manual. EUA: Ed. Lippencott Williams & Wil; 1992. — Costen JB. Syndrome of ear and sinus symptoms dependent — Arellano A, Picco I. Toxina botulínica en la distonía muscular upon disturbed functions of the temporomandibular joint. Ann de la articulación temporomandibular. Revista Odontológica Otol Rhinol Laryngol. 1934; 43 (1): 8-13. Mexicana. 2008; 12 (3): 142-148. — Ramfjor SP, Ash MM. Occlusion. 3ª ed. Philadelphia, W.B. Saunders Co; 1971, pp. 128-134. — Schwart L. Disorders of the temporomandibular joint. Philadelphia, W.B. Saunders; 1959,www.medigraphic.org.mx pp. 132-137. — Schwartz L. Afecciones de la articulación temporomandibular. Buenos Aires: Editorial Mundi; 1963, pp. 265-297. Mailing address: — Farrar WB. Craniomandibular practice: the state of the art; Isaac Guzmán definition and diagnosis.J Craniomandib Pract. 1983; 4-12. E-mail: [email protected]